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20 but I think maybe good evening, everybody. Well, I say good evening. It's the evening where I am. Welcome to another of the land with nurses sessions. My name is Michael. A little. I'm a nurse and founder of Learned With Nurses and I'm joined this evening by Joe, my good friend and colleague Joe Horse Joe, Say hello. I'm sure many of them know you're already Hi, everyone. I'm Joanne Halls. I'm also a nurse. I'm the clinical director of Low with Nurses. And it's lovely to be with you this evening talking about this really important topic with my mate. Absolutely. So I put back to the slides now our session. Remember, if anybody does social media, we are hashtag alone with nurses at loan with nurses. Although this is a very special session and we're doing it in collaboration with smart health solutions. And we have been supported by by actress So a huge, big thank you to buy actress to help make this happen. We have a plan for tonight, and our plan is we're going to be talking about v t e venous thromboembolism in the hospitalized patients. But I think before we start Let's have a little think about who you are and where you are. So Joe and I have loaded a couple of polls already, and I'm going to put a poll out there to say, Where are you actually joining us from? So we're looking at this now in the context of which continent and anybody that has joined us when we used to use a different platform. I used to put this out there so hopefully you can all see. And we've got Africa, Antarctica, Asia, Australia, Oceana, Europe, North America and South America. So at the moment, Europe looking like it's in the lead and I'm going to let that one roll for a little while because I can see wow 20 that well, although we know you're in Europe, we don't know which country you are in. So please do also use that chat to be able to let us know which country you're in Now. We may do another pole in a moment or two after we found out a little more of and what we're going to be after. Joe has given us some quizzes results. So tonight, as I said, V. T in the hospitalist patient and we are going to give you a whistle stop tour through. Well, it's quite a lot, Joe, isn't it? Really, We've got to get We're going to think about who's at risk that. How do those plots happen? What are the signs and symptoms along with? How do we get the diagnosis? How do we manage? How do we prevent challenges and barriers and simple steps, simple steps to success? But before we start, But before we start, uh, let's have a look at that quiz, Joe. How do How do people do? Well, you know how I love a quiz, and you certainly do. I don't even mind winning. It has to be said, um and, well, really, we could do better. So I don't know if anyone anyone that's joining us this evening actually took part in the quiz. I'm not going to tell you what I got the first time I did it, but suffice to say I've I've done quite a bit of learning, um, particularly around statistics in preparing for this webinar. But our average school across the 10 quiz questions that we had was 45% so less than halfway there for us. And shall I tell you which question people found the hardest? Well, Joe, I just popped in there a pole as well To say, Have you done the quiz people can be doing that One happened. Yeah. Anyway, the hardest question, the hardest question that people found was question for which was asking what percentage of medical patients accounted for the total number of hospital acquired V. T. E s. And the answer. I'm just going to click a yes here because I did take the quiz. Um, the answer was 75%. So three quarters of all hospital acquired DVTs happen in medical patients. And as you can see from the graph up there, the majority of people vastly underestimated just how significant this is in medical patients. So I'm going to let us know now a little bit about just exactly what is v t A. And when we're talking about now, when we've been putting this out on social media, I have had people coming back saying, What's VTs? So I have to say, Well, that's what we used to call or we still call it the collective term for pes DVTs and sgpt so pulmonary embolisms, Deep breath from base and Joe and I, as cardiac nurse is sgpt was something very different for a superficial vein from basis is what we think about. Now I'm going to tell you a little bit more about those clots later, but I'll ask, Does she can just let us know? Is it is it important? Why should we worry about VTs job? Well, we're here, So, um, I think we all know it's pretty important and why we're dedicating this time to talking about it now. You and I have been doing some a little bit of work earlier, putting together some podcast on this very subject. And when I gave you that top statistic there that every 37 so seconds someone in the western world dies from Evita, you were pretty horrified. And I know you've been tweeting about is something that we can surely do better. So one in four people die around the world and causes that are related to blood clots. And you know you're going to tell us a bit more about how the blood clots are made later on. Now, over half of be tea cases happen while people are either in hospital or in the period directly following hospitalization. And DVT, sadly, is the number one cause of preventable deaths in hospital. And it's that word preventable that we really, really could make a difference on this. So let's have a little look. I'm going to give you a bit of a whistle Stop tour of some of the figures from here in the UK before I put a challenge out to our lovely guests this this evening. So in terms of the UK and if you could put that next little graph up for me, Michaela is driving tonight. So sorry knows where we're going to end up because geography is not always easily lost, I think is the question. I think so, Um, so you can see from here. So this is, uh, this graph is looking at how the rate of risk assessment for V T has changed here in the UK and for the past 12 years. I think now there's been sort of a mandatory data collection all the hospitals everyone's participated in on how much risk assessment doing in patients are good, admitted to hospital, and as you can see we're doing pretty well, but there are still gaps. There are still people being missed, so there is still some work to be done here. Um, now as well as, um, they're being, you know, slight variation there in the risk assessments that's happening. There's also some variation in the rates of V t that are occurring. So this all of these data on these few graphs I'm presenting now from the all party Parliamentary Thrombosis group, and this is from a survey that it did in 2019. And so if we look at the rates of hospital acquired thrombosis, you can see there are some really variation between the region's just here in England alone. So if we look at the south of England and it's divided up into the Southeast and the Southwest here, there is a higher than the national average rate of DVT. Whereas if we go to the north of the country, the rates are slightly better, so doing better in the north and in the south, which you know is often not the case. We often think about things being healthier and healthier and wealthier in in different areas. Um, in the south of the UK and if we look at who's getting these VTs and how, um, there's a lot of stuff piled into this graph here, but looking at the green bath at the front there, um, 40% of all of the hospital acquired thrombosis that's happening in the UK is from people patients who have not received from both prophylaxis. So that's that preventative treatment that is so important and the grave are slightly further along is the bit that's telling us that most of the hospital acquired thrombosis are happening in medical patients, as we mentioned a little bit earlier on. So where's the trend going? Well, if we take P s as an example, um, we're seeing more PS now, um, than we ever have done. And I guess you could argue whether we're better at looking for these things and assessing risk and finding out what's going on before people have, um, disastrous consequences. Because although there are more PS happening, the outcomes are better than they were, say, 15, 20 years ago. So, you know it's a balance here. In some areas, things are looking a little bit better, but there is still an awful lot of work to be done. So that's a snapshot for us here. So we know we're not all in the UK with different areas of Europe, different areas of the world. So the challenge for you is to look at what's happening in your country. Now you can see our little world map up here from the journal of From Basis and Home Yes basis, which is just a year old now. And you can see that there are really geographical differences here in the use of thromboprophylaxis. So do you have a look at your country and see how well you're doing or not as, um as the case may be So that's a little bit of the background on them. So, Michaela, why don't you tell us how it all happens? Thank you. And yeah, How does it happen? Well, they are clots. Okay, that's the first thing to say they are clots. And I'm going to talk in a bit about how those clots actually form. But when we're thinking about DVT, we kind of blump it into the risk factors into two different categories. We have those that are inherited, so that means people are more genetically predisposed to developing those clots, and you can see here on the screen what's there but in the context of what we're going to be talking about tonight. Of course, those those inherited conditions due to influence it. But we're really going to focus as well on those that are required and often acquired whilst in hospital. And you can see there that there is a very short list of potentially acquired risk factors. But not all risk factors are that are not changing. Not all risk factors are the same, and this is kind of the thread that I'm going to go through now. And the fact that not all clots are the same. Not all risk factors are the same, and that leads us into where we get to the scoring system and trying to decide just how much somebody might be at risk of developing those clots. So we divide our risk factors into those that are strong, and we're going to have they're moderate and then weaker risk factors and the ones we can see here well, there are ones that you may well think about. And that's that you know any sort of trauma fracture. Certainly a previous history of a DVT is a very strong risk factor. Now. We can also see on here and the question that lots of people got wrong on the quiz as well. For those of you that haven't done the quiz, this is an opportunity to get an answer right that hospitalization for heart failure or a F within the previous three months is a strong risk factor. So it's really thinking not just here is that patient now that you've got in front of you. But what is there history? What has it been all about? So that is our They're what we call the strong risk factors. Then we've got slightly larger list of things that are moderate, and you can see these are all things that people often have when they're in hospital or they come in the hospital with them also. So whether you're thinking of your immune diseases, people with heart failure, but also HRT are coming in for different investigations and having those, um, venous lines in and intravenous catheters and those leads that all of these create the potential for clots to happen. That's what we're looking at here on that potential. So there still moderate and we've got even bigger list of moderate. We have another set here again, ones that people will think about, you know, the the contraceptive pill. But would you be thinking about I B s? Even irritable bowel syndrome is a moderate risk factor for VTS. So when we're doing our assessments on patients when they admitted, we do have a short list and I'll be showing you those our list is quite quite long now. These are the weaker factors that come through. And we found that in the quiz a lot of people thought bed rest for more than three days was quite a strong risk factor when actually, it's one of the weaker risk factors when compared to some of the others. Of course, we've got things that we know As we get older, we just develop a lot more problems as well. But things like hypertension, diabetes, things that we would expect to cause clots do so. Not all clots are the same. Not all risk factors the same. And we use the term clots a lot. So we we've talked about VT. Now when we talk to patients. We talked about clots, and not all clots are the same. So we have. You know, clots, in essence, is made up of blood there blood, and they happen for different reasons. Now we have our circulatory system, and that's the system that carries blood. And I don't know why. I always feel the mood to do this motion of circulation happening joke around the body. And when blood leaves the heart, it goes out in that arterial system and our arteries. Well, who doesn't love an artery of the articles? Arteries are beautiful things, and arteries are very powerful creature with special linings, and they cause a certain type of clot. Now that clot is often due to some sort of trauma or damage to the inside of the artery. And that's that's what gave us our jobs for many years. That's a heart attacks and angina's and strokes. So those clots happen as a result of some some damage to the inside of your endothelium that special lining your platelets become activated and you cause a clot. You cause a clot to try and stop that leak. That is not what we're talking about when we're talking VT. Okay, that's not that sort of clot. That's your heart attack. That's your scheme. Yeah, that is a very platelet driven part. What we're thinking about is that venous system now veins of very different creatures to our arteries always think they're little old floppy things that bring blood back up to the heart. And they Well, I'm sure they're not as floppy as you think. That the little floppy things with some valves in to stop the stop the blood from going back down. And that's our venous system. And it's that venous system that we get the clots that we're talking about today. And those clots are really they're fiber in rich clots. So if you imagine if you've got a bucket of blood now, most of us don't have a bucket of blood hanging around. But if you've got a bucket of blood or maybe a cup of blood, then rather than a bucket and you leave it on the side, it's going to form a clot, and it clots because it's not moving. So the way it clots is different. And so that's why when we're talking about V. T. A. Were thinking about those venous clots, and we have to be careful when we talk to patients. And it's very important that we do talk to patients about about the formation of clots and that what we should worry about, that we don't get them confused because not all clots are the same. But not all clots are equal now. As Joe knows, I'm not very good with geography. But the closer the heart, the clot is to the lungs, the worse it is for you. So a clot that sort of happens down in your peripheries down in that distal region is not going to be as bad for you as something that happens closer to the lungs. More like that p. So the risk increases the closer it gets to the lungs. But the risk also increases, whether it's symptomatic or not. So if you say have got a proximal DVT, that is going to be worse if you've got symptoms rather than an asymptomatic one. Of course, the worst symptom you can get is P with death. And when you listen to the if you do listen to podcasts, Joe and I certainly have some thoughts and discussions about those fatal pes and I have to I'm not gonna You know, I'm not going to say them here, but if you don't want to entice you to listen to the podcast But I have vivid memories of two fatal pas that I I watched I saw whilst I was at work. So not all clots are the same. And not all clots are equal now according to where those clots are. Okay, so it's different symptoms. So, Joe, my symptom queen over to you. It does indeed. And as you described at the top, when we're talking about CT, we are talking about DVTs deep vein thrombosis, pee pulmonary embolism, and then are superficial vein thrombosis, also known as from both phlebitis. And so, as you might imagine, depending on where about in the body is being affected. That's where you are going to see your symptoms coming through. So we'll start off with the DVT, and what we will be experiencing seeing then is, uh, swelling. So normally be in one limb, you could be really unlucky and have to going on at the same time. But one leg, possibly one arm. It does also happen in your arm um, swelling that is accompanied by pain or tenderness and warm to touch. So hot, swollen, painful. Often you'll see some discoloration to the skin, reddish or possibly even a bluish tint to it. So in one of your limbs and a generalized pain tenderness now P, as the name might suggest, is what's going on in your lungs, and that will usually be characterized by a sudden shortness of breath coming on that may be accompanied by a sharp chest pain. Now we know that chest pain can occur for multiple reasons. So this differential diagnosis is is really important at this point, Um, so that really nasty, sharp pain, but it will usually get worse on inspiration. So take nice deep breath and you'll get that sharp pain in the lungs, usually accompanied with a rapid heart rate and can be accompanied by a unexplained cough. And often people will be coughing up some blood street nastiness. Um, when they are coughing there. Now, the final one of the trio are from both phlebitis or superficial vein thrombosis. The main difference here because this is going to be in a limb. We've got our fellow. In fact, I think we might have even use the same picture. But the key here is, um, that this is very much more local allies. So with the DVT that you might get the swelling and the discomfort overall in the limb here you can You're pretty much going to be able to point to it. So it is in a specific area. There will be pain, tenderness. It might be itchy. It might be red or the skin might become hardened around the edge. And often you can see that stickiness in the pigmentation of the skin that can actually hang around. So this these symptoms can develop over hours, possibly days, and they can take the same sort of time to resolve. And that hardness of the vein could even go on for months. So, um, I think when we were again not not promoting our podcast in any way, shape or form But I did. This was an angry vein. It's very much an angry vein. I just imagine it would be annoying. Yes. Yeah. Irritating and angry. I'll leave that there. I won't. I don't I don't know. Anybody know at all, So I guess the next bit to move on is really around the prevention. That's why we're here. That's what we're most interested in. So I will hand it back over to you to talk about preventing BT. And I'm just going to go in and answer Juliet's question here. Lovely. Thank you. Thank you so exactly. So the best way to do is to prevent to prevent a DVT or P is to prevent it, and we have have quite structure processes to do. That job has already mentioned that, you know, between the medical and surgical patients and that medical patients make up quite a significant proportion of those VTs that are there. And of course, Joe and I've been chatting about this quite a lot, and we were saying, But you really think of surgical patients when we're doing this, you have memories, you know? Well, you know, either going and having operations or patients having operations, friends and family. And you think right, the surgical patients, they get assessed legs, get measured, all of that. And whilst we do think about it in context of medical patients, it's not necessarily high up in our brain may be what it should be or we do it because it's part of a reassessment. You come into the hospital, you've been admitted. It's part of that tick box, but without really understanding the impact of what we're doing when we do that and that that 11, every 37 is that it's more important than the fact that we do do this. And so we do an assessment now we have nice guidelines in this country, but it's the lines that are in your country, so they should either be done by a professional network. For us, we've got a national body, or or even from a peer reviewed journal because we know countries are all different shapes and sizes, and not everywhere has that same structure that's there. And that says happen as quickly as possible as soon as they have been admitted. And certainly by the time there's the first consultant review, we have to have that decision made. Does this patient need thrombo for prophylaxis? And what we're trying to do? There is balancing out the risk of forming a clot versus the risk of anti coagulation, and we do it a lot, don't we? You know, throughout healthcare and particularly medicine. It's looking at that. Getting that balance right is the intervention that we're going to be doing better and have less hazards and less harm to patients than if we don't do something. And that's exactly what we're going to be looking at here. So I'm going to talk you through a variety of different guidelines to start with. So, um, the first one we're going to look at is the nice guidelines and many of us now this is probably going to show up very, very small. So I split it into a couple of years. They will will take it step by step, and the first one is Step one now. These are being produced by the Department of Health based on nice guidelines. And many different organizations of trusts have adapted these into their own local sets of policies. And in your area of work, you will have some where, particularly if you're in the UK, it's as Joe said, it's a part of a national data set. We have to report on it, Um, so those reportings will happen. Step one, and it's a 12 step one, and that's exactly what I said. We really need to assess our patients as soon as they come into hospital. Actually, when we're thinking about their mobility. So we said that being in hospital and being in bed is a low risk. But actually, when we come in to hospital, we don't move quite as much that also influences are thought of risk. Then we start going through those big tic boxes that we have deciding on. What are the risks for that patient at that point in time. So there. So some of the risks that I mentioned earlier on It's not all of them. It's some of them now we can see here whether we're a medical or surgical patient, but also are they? What's their age? Are they dehydrated? What's their weight? Have they got a past medical history of DVT? Any problems with phlebitis? And they're what we call a patient related risk factors. And then we apply next to that the admission related risk factors. So people walk in or have these conditions, or have these risks to start with what extra is being add to their risk when they're in hospital. So is it that they're in critical care? Have they got are they having surgery? Is that that hip replacement? So there's there's a whole layers of things and that gets us prizes, and the prize is is getting close towards needing anti coagulation. Now anti coagulation is not without its own bleeding risk, and we can see this here. That's again. That's another another scoring system. So it does feel that we're forever to boxes, However, what we're trying to do take approach to making sure that we don't miss people and we are missing people because one every seven seconds means we're missing it. We saw on some of the stuff from the old party parliamentary group that we are missing that opportunity and talk a bit more about the challenges that we have in a moment as we come through. But again, that bleeding risk we have patients related. So what have they got? But also the admission related. So we know that actively bleeding and that's a really big, really big risk acute stroke, old hypertension, and what have they come in for? They come in for spinal surgery, I said those highly vascular areas now, depending on what that risk is on depending on whether we move forward. So there are two risk, too, that we use. That's our risk tool that we use in England. But of course we're joined by people from all over, and I So we've got people. I'm from Lithuania, Egypt and Joe. I get very excited when we see people putting in the chat where you're from, so keep throwing in. I can't see the chat at the moment, but I'll have a look in a moment. But there are other risk tools out there now. The two that I'm going to talk about briefly is Capri Me one and their differences. It's a society of cardiology, the American Society of Hematology or even the C. D. C. They are all over the place, but risk assessment tools don't want to leave them in the cupboard. On a folder on your computer, you have to make them kind. You have to turn them into more than just going to take a box. You understand the implications of what you're actually doing and act upon them. So do a risk score, and this one is for medical patients, and you can see in here then it is the same sort of risks that are there. So whether it's previous P t reduce mobility or whether their what their ages, heart failure, heart attacks and then this one, if you score five or four more, then that's counted as a high risk and you would move forward towards anti coagulation and we'll have a look. My payment. What that might mean, um, and the premium. Now this is for surgical patients. And this, well, this you got more risk factors on here, and they are. You know, I think when it comes to these risk assessment tools, we don't expect anyone to remember every risk and what every point is worth. It really is knowing where to go and get yours now for this one. For the Capri, anyone were again categorize people into low, moderate or high according where they are. And some points, you know, risk factor can get you five points, and that's whether it's to do with multiple trauma or stroke. It doesn't take a lot for a patient who's in hospital to actually start clocking at the point. So I think we can see that most patients I would suggest it'll probably or many patients will probably benefit from some form of thromboprophylaxis treatment risk score range for Capri me, then depending what we do. It depends on what their score is. So, as I mentioned briefly there, we've talked about the low, high risk score. But you can have even higher risk course when it comes to the Capri Me one and really what we're trying to see. And then what we can see here is that early ambulation and that's what we be important. So as well as giving, getting our patients moving. And I think that's something gentle touch is absolutely essential in so many ways. Now I'm just going to show you one more, and you're probably thinking, how many risks scores can you have? But I do like I love a scoring system because to me, what that means is it's reliable. We're not just waiting on patient people's judgment or you look like you might be able to risk, but that we've got that system. Last one I'm going to mention is called Improved Bleeding Score that's actually available on line, and you can go in and you start filling it in and here, and that will give you your percent and what you can see. If it's less less than six. They don't have an increased risk, and it's six. I can't even if it's less than seven. The risk is not increased, but if it's greater than seven, risk is increased and you can see the same scoring system that happens there. So we've got a variety of different tools we know that we want to do is as soon as patients are admitted, whatever they're admitted for, we should be using an appropriate risk assessment tour and recording it and acting upon it. But what are we going to do? Job? How are we going to stop these clocks? Well, like everything that we look at, preventing is always better than having to find a treatment. Of course, this is across the board in cardiovascular disease as well as in multiple other conditions, and the key here is around that prophylaxis. And if we are going to use pharmacological VT prophylaxis for medical patients, it's so important that it started as soon as it's practically possible, and absolutely within 14 hours of that admission, unless there is, uh, some kind of population specific recommendations for the patient and the group that they're in. So, for example, patients that are having an acute cardiac event, an acute stroke or other forms of acute illness there may be slightly different rules on what is appropriate for them. Um, thinking about people that were admitted, too critical care people that may have renal impairment, malignancy, psychiatric illness or patients who are receiving palliative care. So when you look across at the guidelines and having spent quite a quite a bit of time looking across the nice guidelines, there are very many different groups of people where there are slightly different variations on the recommendation. So it's important that you are much like your risk or selecting the right page for the patient that you're dealing with, you know, is quite a complex matter. So again, like your risk score is, there are multiple sets of guidelines. Um, depending on where you are, we have nice here in the UK I was just looking back at our, uh, pole where people are from, and I think we do have some guests from North America. We have some from Africa as well. Um, so here is an example. We have the American society of hematology 2018 guidelines for the management of the tea, And this is specifically looking at prophylaxis for hospitalized and nonhospitalized medical patients. And if we were to to look at this in more depth, Um, there's a total of 19 recommendations, um, available within this guideline, but it's recommendations 12 and three that were particularly looking at for patients who are acutely unwell, uh, in the hospital, and it takes you through again, weighing up pros and cons. Balance is what is going to be the best option. So from using a parental anticoagulants agent or not, using low molecular weight, heparin versus unfractionated heparin looking at fondaparinux versus low molecular weight heparin or against unfractionated hyper as well. So looking at all the different choices of agents that we have and weighing up the pros and cons according to which particular patient group that you're looking at, so a lot of guidelines out there again, you know, this is the same recommendations for everyone. Look at your patient group, look at where you are and follow the appropriate guidelines for you. But of course, it's not all about the medicine. It's not all about anti coagulation. There are other meth of prevention that we also use on a regular basis and could probably use more of so. Most commonly we have those lovely antiembolic stockings that I'm sure most of us have wrestled with or another. And you know routinely, though, seem to get a packet tossed every once they come through the hospital door. But it's not quite like that, but we need to be cautious because even the non pharmacological interventions can have complications and issues as well. So we need to make sure we're using the right thing on the right patient. So, for example, if patients have some form of occlusive arterial disease, they've had previous bypass surgery involving the lower limbs. If they have any sort of sensation problems, peripheral neuropathy or or some other form of sensory impairment, they're local skin problems. Any allergies to the materials that these are made of swelling or anything that's going to mean it's it's difficult or non impossible to get a correct fit. So we do have to use our caution clinical judgment, particularly if people have got some form of wound there, too. But as I say, it's not just about throwing the packet at someone and leaving them to get on with it. We do need to make sure that we're measuring patient's legs and using the correct size garments for them. And so they should always be fitted and patients shown how to use them properly by staff who are trained in their use. Now I know you're going to talk a bit more about training and the like a little bit later on, but it's really important we are checking for any swelling. Um, patients have had any surgery, and if there are any changes in dimensions that we re measure and refit those antiembolic stockings and, uh, you know, we need to also monitor them once people are wearing them and encourage them to keep on wearing them until they don't need to anymore. So otherwise, when they are much more active up and about. And they do need to come off for washes, showers, etcetera as well, but particularly so that we can have a look at the skin condition underneath them. So thinking, particularly about frail older people, If there's problems with mobility, problems with skin integrity or any sensation, then you know they might need to come off several times in a day just to check that there's there's no injury, soreness or nastiness lurking underneath them. Checking people are wearing them properly now. We've all seen them rolled up, roll down all manner of situation two in the vein, attempt to make them slightly more attractive and comfortable than they actually are. But we do need to make sure that people are wearing them as instructed, and we also need to be able to stop them. If there's any problems with the skin or pain and discomfort that happens, um, it's suitable. There are other options now, Michaela. I know when we were talking about this, you were example when I mentioned alarmingly so I think. And I'm I'm kind of expecting inflatable boots. Um, at the Christmas party, it has to be said, um, so by inflatable boots, we are talking about intermittent pneumatic compression, which is a a newer depending on how long you've been in this game or out of it. Um uh, probably a newer car except than the stockings. And this essentially is an inflatable garment usually boots that you can put on and we have. It's connected to an air pump and there will be a cycle of inflation and deflation. So a bit like the mattresses, you know, when the air mattress is first came out with a different cells would inflate and deflate. And so there will be this side within the boots. And so that's going to stimulate the normal pumping movement. We would get in our leg muscles from moving around. So getting that blood moving, stopping it from just pooling around, being static and obviously increasing the risk of clots being forming. Now, Um uh, like with everything, there are always some slight practical issues around comfort and having the right kid and all the rest of it critical care, particularly good to using them. But you know, often patients are perhaps not as awake in there to be able to have some of the problems that we've reported there, but they do need to be prescribed. But you know, there are There are lots of things available there for for prevention, shall we say, but because things don't always work out the way we would like them to do they know this is where I jumped back in. I think Joe isn't it says. And even if we have done everything was posted. We could still suspect that bte. So we need to always be aware of it. But we know that actually, people aren't appropriately treated. Then that really does increase the risk. And we saw that, actually, people who want your earliest Lijie that the people who actually to have the of those that are not are not receiving thromboprophylaxis. So let's start with as soon as a V T is suspected. Now let's just start with Let's start with the worst first and that's your Pee. And we've already had of those symptoms. Although one of the first one of the another symptom of, um P is death and and so some people can die very quickly can be very, you know, from nowhere. It almost feels like that that he appears and boom, they've gone. So, um, but let's assume that that hasn't happened, and that's not a fatal pee at the moment. But what we want to be able to do is assess how likely is it that they have a P? I got those symptoms, you know, the pain and the cough thing might be something else, but we want to be suspicious of it, and we use This is again based on on the on the guidance. A nice guy didn't say for England, and that is the well here. It's another scoring system and we do have a lot of scoring system. It needs to be said and four is the magic number, so we get three points for science and symptoms. We get the points at an alternative. Diagnosis is less likely than a P, and then we'll start to go down depending on the heart rate mobilization, previous history of DVT malignancy hemoptysis. So they really you know, it doesn't take a lot to get the four points. If you've got this pain that's going on, So what do we do? Well, we use it Another flow chart. In real life, this happens a little bit smoother than us having to, you know, you're not flicking three pages and pages. It's often logic built into software to really help us make that decision, we use the well score now almost. Whether we score for more for is the magic number for this. We need to think about starting somebody on interim therapeutic anticoagulation while we're waiting, if they haven't, if they're not already on it, we need to think about starting it. So let's imagine they scored four or more than what we want to be able to do is jump straight in with the CT pulmonary angiogram. And that's really getting us to get that definitive done basis. It's a pa, but we don't wait until then. Patients we start, start that thromboprophylaxis. We start anti coagulation. If, of course, that that and that pneumonia angiogram is positive. Well, you already started your anti coagulation. You started having that clot early, so that's good. Now, if it's negative and you're worried that might be, then what? You want to do it towards the ultrasound and you've already got your hopefully your anti coagulation on board. Now, if the well score is for or less well, that says your PT is unlikely, but it doesn't mean that it's not there. So at that point, we might still think about, um, anti coagulation. Of course, this is done on a clinical decision, if it's more, but then we're starting to look at that D dimer test. If the d dimer is negative. Then we can stop the anti coagulation. So a negative d dimer means we can see. But if that D dimer was positive, then really we want to go and start looking at that. Is there any other clots anywhere else sitting there? We may be seeing the one on the leg, but is it back in the lungs and what are you thinking of? So So that's if we suspect a PT Now, if we suspect a DVT and that's looking at that, um, looking at the patient as Joe said, they might have a very sore swollen. So we're going to do more. Just, uh, look at the limb, though. We assess the whole patient that's there so we might see that sore swollen we might be. It might be tender and stuff. It might be a agitate. Measure out. It is a bit bigger again. What is? Who is the rest of that patient? Have they been in plaster? Have they been? Have they been immobilized for awhile? Cancer Have they had? And this is one. And I think again always comes out. A bit of they had major. So within 12 weeks. So you're really thinking. Not just that, the person there and then But what is there history in the last few months that might be influencing their body's ability to make that clot? If the score again is we can see on our our it's another scoring system, we have another scoring system. So if again, if the Wells is greater than two, then we want to be able to do an ultrasound scan on that leg. And we want to do that along with the D dimer and then if it's less than one we do with that. And if your D dimer ends up as negative, you can stop everything. But if the scan is positive or you have a d dimer that is positive, you were almost keep scanning until you find the negative. So it's really hard. We don't stop that into coagulation until we get a double negative on both. So that is what we do or what we should be doing. I'll say doing in England, there are other guidelines for other countries and this is where we're going to look a little guideline heavy for a moment. But I think it's really important to understand the evidence that underpins what is what is being recommended. So the European guidelines is something that many people use many people use across different countries. And again, you can see here they're talking about that initiation of antique regulation without delay. What the risk of that patient, while trying to decide, Do they have a peeling? How is the DVT going on now? Deciding what to use again is based on local prescribing areas. So let's delve a little further into the guys guidelines on what they're actually talking about. So these guidelines of phased to look at starting with the patients who are most at risk those at the higher risk. What do we go for? So we can see the best evidence here for our patients who are more at risk and that is looking at antique regulation? We're really trying to clot, and it's only if we or if Thrombolisis crisis is Contra indicated or it hasn't worked. Do we then move on to think about something surgical like an embolectomy? There is other evidence for different ways to try and get in to sort it out that clot, but this is again in our high risk for your patients. The evidence isn't as strong as that anti regulation that's there now. When we move into our patients that are more into or lower risk of PML, it's still the strongest evidence of anti coagulation. Whatever that virgin is, you use your little guidelines whether that's your trust, your organization, your hospital. Wherever you're working, follow your guidelines and it's about getting patients on the right appropriate medication as as soon as possible here. Now again, in these intermediate and local patients, there are other things we can use. The evidence again is not quite as strong, and I'm going to take us through to some of these ones. Looking is re profusion treatment, and we might be thinking about really assessing that patient. Who are they? What is wrong with them? What is the level of hydration like? Are they already on 30 coagulation? What sort of surgery that they have had? And we're starting to think about different Um, yeah, quite a holistic for patients. It's interesting that low, but I would say some BP is actually essential in knowing that, and we'll come on to this one at the moment into coming on to a whole system approach because it's not not one person's responsibility, and I'll be picking that one up in a moment. But remembering your risk of PT and he wants you the hospital, it continues on. And so there is also a role for community primary care also being aware, and patients being aware for what that risk is and it continues on. And some patients might need to be discharged on approach with the therapies. So this is a very busy side. That is, our prescribing guidance in, uh, Anticoagulated medication for DVT or PA suggest for you is find out what is yours for your country out. So Joe and I have tried to do is take you on a journey on why and how and how we can do it in different elements. But I think now what I want us to think about is that multiplicity disciplinary team who is responsible? Well, I've just been having a nice chat with Roseanne on the chat about putting your stockings on. Okay, I'm going to have a little look at the chat then. So we need to maybe have a video demo of something like this because I think. I think the wrestling analogy with them is resonating quite nicely with people, so we can have a little chat about that at the end. But as you rightly say, it's everybody's job. So whether you are, you know, in charge of the show, you are the chief medical director of the hospital. Uh, you know, you need to make sure that there's a policy in place that's implemented and much like you said, with your scoring system, having something in the cupboard or not referred to is, you know you can have the best policy in the world, but if it's not implemented, then it isn't going to make a difference to patients. So as we kind of go down the ranks that were then it's everybody's job to make sure that these policies are there that implemented, that they're adhered to in all of the areas that they are monitored, um, and appropriate. I know you're going to talk about audit in a minute, but the appropriate data is, um, corrected down to the individual level of the clinical staff who are looking after patients to make sure that they are using the correct risk scoring system to make sure that they are recording things in the right way. So for most of us nowadays, that will be a digital record and electronic patient record of some description. This is something that certainly in this country, the regulators will, um, look at and assess when inspections are being done to make sure that these things are actually happening. Um, so, yeah, through to the prescribers pharmacist to make sure those prescription charts are their treatment plans are in place. So it really is a huge team effort to make sure that we have everything in place and it's being followed. So, looking specifically the practicalities of what we could do well, I think we've learned from you that that assessment and that continuous reassessment process of patients so we couldn't keep our eye on their risk level and their situation and make sure that we are in a position to be able to treat um both in terms of prophylaxis but also looking out for any symptoms and, as I think you said, leaping on them when they occur. Um, but in terms of prevention, you know, it's it's it's not just for our lovely physios to be encouraging patients to move and mobilize and do passive movements if they can't get up. You know this. This is for all of us to encourage people to mobilize and to encourage them to stay hydrated as well. And we all know how busy everywhere is these days. And, you know, we we've we hear stories about patients, you know, not being able to be dehydrated when they're in hospital, you know, access to fluids, having help, to be able to mobilize to the bathroom, to get washed, and all these kind of things. And, you know, everywhere is busier than ever. So, you know, we can't underestimate some of the challenges. And I know you're you're gonna come on two Um, some of the challenges that we face and educating ourselves, educating our colleagues and educating, of course, our patients, because there's an awful lot that patients can do to help themselves or relatives can do to support patients. And this is, as you rightly said, not only for for that period of hospitalization, but also thinking about when people go home as well, so looking out for symptoms, and that's this is where our education comes into for people to know what to look out for. Because if you just say you want to be looking out for any blood clots, Um, I'm not sure many of us would actually know where to start. So, you know, being specific about what we are actually looking out for so that patients and relatives can keep an eye out for that. You know, it's very hard to see somebody's hot, swollen leg when it's buried under a do, for example, for people to understand why it's so important that they are as mobile as they possibly can be, that they stay hydrated and to make sure that they let us know of any problems that they're having again. We're also busy. Everyone's rushing around, call bells, flying off everywhere, telephone calls going off everywhere. It could be very easy to see everything. I can't give them another problem to think about, but we do need to know. We, of course, need to know of any more problems that people are experiencing so that we can take the right action now. I've probably touched on quite a few of the challenges and barriers that we face there, but well, I can think of a few more. Don't you? Don't you? Exactly. So you know it's implementation is what Joe and I love and I have made reference to. Protocols are no good if they sit on the shelf. And all too often we've seen that, Joe, haven't we in action that well or not in action as it goes? And you almost wanna have that balance because you don't want to spend forever having to take boxes and fill this in and fill this in and, you know, without actually being neo patients. But equally, we do need some sort of structure and rigor to to be able to make sure that what we're doing is in a consistent way and that it is auditable. So I love a good audit. I think they made somebody blush once when I said it that way. But I do. I love a good audit, Um, allows me, and I think that's the public health side of me as well. That allows us to really see not just where we're going wrong, but also allow us to see our success is, too, because, you know, it's not all doom and gloom. There is a lot of fantastic work going on out there in trying to prevent VTS and it's really finding out more of that and I certainly when I was doing some work looking for this NHS Digital has got some really great case studies of what's happening. So you've already touched on that time time and you know, we've had the pandemic. We've got that next wave coming through now. There's never been so many. You know, the whole world is short staffed. It feels like in the health service, so your pressures are greater than ever. But let's just think very practically that. And I and I have to say, because it's been a while since I've been in the hospital. I don't think I've ever had training on how to put a V t on, not in a systematic on oh, to put Oh, it's late. How to put How do you want one lately? Have you know how to put on those stockings? I I don't think I've ever been taught how to do that. So So whether you're a nursing staff or medical staff, then we need to have make sure during your induction and every two years that you should be updated on V T. E on the prevention, identification and management. And there is, um, a Department of Health. Safe as in England, there's any learning module. Hopefully, you've got something relevant in your area and for anybody who wrestles on with those stockings should have training to wrestle on with those stockings. And I was about to put in the chat to Annemarie that I put them on. I put them on my daughter from time to time, and I use, um I use a carrier bag. Now, I don't know if the carrier bags are loud, but I'll use a carrier of that conversation going on. Was that okay? Carry a bag over the foot. You shovel it all on, and then you pull the carrier bag out the bottom, but the toes, that would be awful. You can get your carrier bag out, then you gotta have devices that help and stuff, don't you? So there should be training and regular training, and I think you know, you and I have discussed V T. E a lot recently there, and both of us haven't really thought about it in the way that we probably should have thought about it, Um, either as healthcare professionals, but also has relatives and friends and visitors and from patients. You know, being a patient from time to time is having more awareness, and I am still flaws by that one every 37 seconds. Somebody in the western world, it's still flaws me, and particularly as so much of it is preventable. So audit training, that good baseline that's there. And if you don't have appropriate tools in your country, go and have a look at the nice guidelines. It has got perfect audit standards you can use. They've got operational. They've got clinical. So you can think about you know what does my trust? What does my organization do? How what should we have as well as each individual person being responsible as well? Um, just don't use plastic bags for non. Absolutely. They won't work at all. I'm looking at the chat and trying to talk about the same. So I'm probably going to just think about those tips now. So for people. And I can't believe we've had people staying with us, the whole our We've been doing this, though now and I think you know the tips are we all have a role to play. We also, whether in hospital, outside of the hospitals, in the community, education and training, we all have a role to play, not just for us, but also we've all. But we've all got family and friends who are going in, and I think there's something out there to make patients more aware to look for those clots. I think we need to be careful of our language when we talk about clots, but asking them, let us know if your leg starts getting a bit sore. All of those signs and symptoms that Joe has mentioned moving and drinking well, it's important for everything, really. And as you were talking about it, Joe, I was having happy memories of dragging my cardio thoracic surgery patients my bypass patients out of bed and getting them out of bed, sitting them up, pushing them down to the showers, giving them a hose down all of that sort of stuff. What probably was very early on in the post surgery time, but the best thing for them was to get up. Um, be aware of the signs and symptoms they're not really going to change, you know, they're not gonna appears not going to look dramatically different in the 10 years town. Those symptoms are still going to be there. So keep yourself updated. Keep yourself going on that training and that early intervention many of us will go. Okay, there's a lot of questions to ask. Tick, tick, tick, tick, tick. We've got to take all of those questions dadadadada without actually thinking some of those questions were asking, is more important than others. And that's why good record keeping data data data is absolutely essential. I think we're getting close to running out of steam. Joe, do you want Do you want to summarize for us? We are, yes. So, um, let's wrap it up then and then we'll we'll get onto the chat and any other questions that people may have. So, um, we know the hospital acquired VT accounts for thousands of deaths annually here in the US, absolutely millions. If we look worldwide, and I'm sure none of us will forget that every 37 seconds, someone in the Western world dies from a V T. And those fatal PS remain a leading cause of people dying in hospital, and ultimately this doesn't need to happen. We can't prevent everything, but certainly we can prevent a lot. We've shown you lots of different guidelines and tools and things that are available for that. But I really find what's right for your country or within your organization. There'll be a policy there. There'll be a guideline there, find it, have a look at it, see what you need to be doing because together we can take up that challenge. And so the biggest challenge, the first challenge is one to prevent. But if we cannot prevent, then we need to detect. We need to diagnose and we need to treat because at risk of sounding like a politician together, we actually can really save lives. I think we should, uh, look at the questions now we should do. I think you put another pole in. I did, I did. I thought, Let's have a look at who's here. So we we worked out which countries people are from and predominantly were from Europe. But we're from all over Europe, Lithuania, Malta. Um, we've got we've got some people from Africa and North America, so we tend not to have a seizure at this time of night because it is in the wee hours, but they're usually very good at a bit of a cat. Catch up in the in the mornings and then. So what I've done now is said, What is your role? And we have some people from the from the HPI side of the world. We've got some doctors, We've got a lot of nurses, and we've got a lot of something exciting because we we just thought, Well, we can't have this huge long pole. So who's pop it is going to pop it in the chat. What is that, something exciting. So Roseanne says drink is important for better circulation. Right? Well, I want to say it depends what you're drinking, Really? But I think what we mean is staying hydrated is what you're thinking about their Roseanne, isn't it? Does it? Does it matter what fluids we drink? Well, um, you know, water is always going to be the handiest thing to drink, and probably something that's not going to be too much of a diuretic effect. But yeah, keeping that volume mark in your circulation is certainly going to be helpful. Keep that circulation going around and not have any little little nooks and crannies where those little clots can form. So yeah, and I think as well when were in hospital people don't drink quite as much as what Maybe they could do at home just simply because that old jug of tepid water, despite it being changed regularly the T round doesn't happen as maybe as often as people would like to have cups of tea. So it really is. It really is important. Now we've got another one. Oh, there's a lot going on. Covidien Jo, what do we think about covert contributing to VTs major clotty, didn't we? We learned that that people were having a lot more clots when they had Covina. And again there was lots of really interesting say, interesting, pretty devastating things that came out of co vid when people actually had covert. And we also I think Roseanne is now, um, talking about the clotting risk of vaccines now. Uh, yeah, that's a big difference. That's a whole different explore, but, you know, But I think I should still be having my vaccines, but I think as well we certainly saw that David major clot. I think that was the bit, but also co vivid. And the Pandel also interfered with getting the anti coagulation. So there had to be a big sea change, didn't and how people being managed with their anti coagulation just simply because they couldn't come in to have their blood tested if they were so taken. Warfarin. And there was a definite shift that had to happen really very fast at that point in time. That's there. Yeah, well, you know, within the hospital, you know, record numbers of patients struggling with staph. We had staph moved around from different areas people working areas they weren't used to, perhaps people coming from areas where they weren't used to doing V T assessments. They used to dealing with prophylaxis. So, you know, it would be really interesting to see some statistics or perhaps quite scary to see some statistics of, you know, the difference that it that it did make. But I suspect that not only, um, it's coded, making you more clotty. Um, you know, maybe maybe they're looking for it. And the prophylaxis and the assessments were also suffering because there was just so much going on that carnage, carnage everywhere. Well, I'm just going back through the chat now, and Dina said, um, stocking. And so and I'm reading it out because not everybody, particularly people. If they're watching this on catch up, they won't see the chat in the same way. And there's a lot of discussion about getting those stockings on and, uh, said stocking applicators of fat. And she's seen a patient on the district using old painting that they took the bottom off as an applicator. So I, you know, devices are available? Absolutely. But I think I think I think I think what I'd really love to hear is people's experiences of doing those risk assessments. So we know we've got lots of nurses and doctors in. So if we could have it in the chat, So yeah, so So Gwen's come in. As as healthcare professionals, our practice is based on evidence rather than rumors. Yeah, so and I think that's the bit Roseanne we don't We don't not have are boosters just yet. I think there needs to be the benefits of that. That booster, the cove it is there, um, that we know that we're having. So I think Naomi asked the question. Way, way, way, way back up here. Uh, evening, Naomi. Um, talking about the oral contraceptive? Yes, Uh, more of a community question. Really? And saying how the nice guidelines are, we know that they're applicable to over 16. But of course, we know the increased risk of the contraceptive pills. And, you know, we do have a lot of girls that are not yet 16 who are pills, Certainly in this country. Um, and I'm sure worldwide as well, so there could be a bit missing there. Now, I'm not aware of any specific guidelines for under 16. You always have this slightly different area, don't you? A huge amount of evidence, as you know, Naomi. One with being asked to put guidance together around high potential of things in the in the past. Certainly with younger people. There's often a great lack of evidence for these things, but yeah, it would be certainly useful to have, um, some more advice on that, I think. Well, I'm just going back to the chat. And Fiona McPherson left a lovely message saying she's in Scotland, but worked in NHS, England, and Scotland, and so far this has been one of her favorite webinars. But there's not enough info and training on the subject when first starting on the ward's all paperwork. No training in the hospitals that she's worked in. And I think that's what happens, isn't it? You end up with a raft of paperwork or it's all computer driven now, isn't it that you have to work your way through without really seeing the reasons why and therefore the benefits of why we're doing? You know why these things are being asked rather than it's just another set of boxes. We've got a tick and get through as quickly as we can. So I think I think, um, I think we're getting close to the wrapping up. We've got a couple of minutes left before I tell people about the exciting next steps. If you have you anything. Well, I've learned lots through, um, talking about this, Um, and and hopefully others have to. Naomi's just put something else. I mean, I think this is about vaccinations. She knows her vaccines anyway. She does as indeed she's the vaccine queen. Um, yeah, Roseanne is saying that today started giving the flu vaccine as well as some people are doing that here, too, um, at the moment. But, um but yeah, as I say, I've learned lots. I hope others have to. And yeah, we've got quite a bit of work to do, but there's got to be some some light there at the end of the tunnel, I'm sure. Absolutely. Well, I just I'm going to wrap up with a big thank you to everybody. So I just now like to say thank you to you, Joy for joining me on this session. Um, we might do occasionally do a longer one like this again. We often do our webinars solo, don't we? So I'd like to say a big thank you to buy actress who, without their support, we wouldn't be able to have done this. And they're doing this together with smart health solutions. Um, but also, I'd like to say thank you to everyone who is joining us today because, uh, hopefully you've learned a little more and Sheldon's just saying it was really interesting, although scary. Yeah, it is scary. And and yet there's a lot we can do. So if you are thinking about what else you'd like to do? Share this with your friends and your colleagues because this is available on catch up. I sound I sound like I'm on the TV on catch up. Um, it's a really available on medal and they get people just have to register and I don't even think you have to register. You can just go and look at it. So very soon over the next few days, what will come out is from from the amazing Sooner is we'll have a dedicated Web page all about the TV, Um, including how to access this, this webinar and to access the slides. And, of course, to access the to podcasts. That job and I have been mentioning yes cast, so there's two podcasts coming up. So it's Joe and I. I'm having a bit of a chat pretty much about what we just talked about tonight, but they're slightly more relaxed, well, more relaxed than we are now. Fashion that's there. So, yeah, and that's the sort of one that it's just audio, so you don't have to look at any slides. We describe it in a way that you don't need slides for it and yet so huge. Thank you to everybody, because I'm I'm, you know, let the nurses. Well, we do it because we love it. And there's lots of people there. And I'm loving hearing the messages from here that people are enjoying it and loving it to thank you, Fiona, for those ones there. So, as always, I am going to pop the feedback here. You follow your feedback, do you evaluation? And that allows you to get your certificate. And also, I've already uploaded a copy of the slides for you as well. So you get the full set of slides to Joe. Thank you very much to you, too, honey. For this, I think we can. So the pod cast on your Yes, I miss that. What you say, Joe? I said thanks for having me and infiltrating your webinar. That's a okay. And Stephanie, you know, has already announced if you make sure that you take to say yes, you're happy to be followed up, the podcast will come out and they're in Fairness is called V T and the hospitalized patients. And it's from learn with nurses. Um, it'll be short and snappy that way. Easy to find, but we've just gotta wrap it all up as a bundle now, and it will all go out in the next few days. Well, I think that's just done, Jay. So I'm going to pop my camera and my audio off now. Um uh, but, well, I'm going to keep the chat out for a couple of minutes, just in case there is anything. Thank you very much. Everybody take care. Goodnight. Goodnight.